Association of low alanine aminotransferase with loss of independence or death: A 5-year population-based cohort study

Liver integrity and the risk of Alzheimer's disease and related dementias

INTRODUCTION

We examined midlife (1990-1992, mean age 57) and late-life (2011-2013, mean age 75) nonalcoholic fatty liver disease (NAFLD) and aminotransferase with incident dementia risk through 2019 in the Atherosclerosis Risk in Communities (ARIC) Study.

METHODS

We characterized NAFLD using the fatty liver index and fibrosis-4, and we categorized aminotransferase using the optimal equal-hazard ratio (HR) approach. We estimated HRs for incident dementia ascertained from multiple data sources.

RESULTS

Adjusted for demographics, alcohol consumption, and kidney function, individuals with low, intermediate, and high liver fibrosis in midlife (HRs: 1.45, 1.40, and 2.25, respectively), but not at older age, had higher dementia risks than individuals without fatty liver. A U-shaped association was observed for alanine aminotransferase with dementia risk, which was more pronounced in late-life assessment.

DISCUSSION

Our findings highlight dementia burden in high-prevalent NAFLD and the important feature of late-life aminotransaminase as a surrogate biomarker linking liver hypometabolism to dementia. Highlights Although evidence of liver involvement in dementia development has been documented in animal studies, the evidence in humans is limited. Midlife NAFLD raised dementia risk proportionate to severity. Late-life NAFLD was not associated with a high risk of dementia. Low alanine aminotransferase was associated with an elevated dementia risk, especially when measured in late life.

Patients with low ALT levels are at increased risk for severe COVID-19

Introduction

Frailty is a known risk factor for many diseases, including COVID-19. However, many frail patients are undiagnosed as the diagnosis can be cumbersome. Alanine transaminase (ALT) is found not only in the liver but also in the muscle tissue, and multiple studies show that frail sarcopenic patients have lower ALT. Frail patients are at increased risk for severe COVID-19. We evaluated the association between pre-infection low ALT and the risk for severe COVID-19.

Methods

We collected data regarding all subjects tested for SARS-CoV-2 between 1 March 2020 and 31 December 2021 from a national state-mandatory HMO in Israel, serving more than 1.3 million patients. Clinical and laboratory data were collected, including ALT from the year prior to infection. Severe COVID-19 was defined either as death, ICU admission, or ≥10 hospitalization days. Patients with low ALT (ALT ≤ 10 IU/l) were compared with patients with normal ALT (11-40 IU/l). Patients younger than 18 years with a diagnosis of liver disease and with ALT > 40 IU/l were excluded.

Results

During the study period, 58,961 patients tested positive for SARS-CoV-2. The patients in the low ALT group were younger (40.53 vs. 42.73, p < 0.001), less likely to be males (12.3 vs. 38.7%, p < 0.001), and had lower BMI (25.97 vs. 27.15, p < 0.001). The patients in the low ALT group had higher mortality (2.36 vs. 0.57%, p < 0.001), more ICU hospitalizations (0.49 vs. 0.41%, p = 0.47), and more prolonged hospitalizations [2.63% (95% CI 2-3.2%) vs. 0.98% (95% CI 0.86-1.1%) p < 0.001]. In multivariate logistic regression analyses, low ALT was associated with an increased risk of severe COVID-19, with increased mortality (OR 1.88, 95% CI 1.37-2.56) and prolonged hospitalization (OR 1.78, 95% CI 1.33-2.35).

Conclusion

Low ALT level prior to infection is a significant risk factor for morbidity and mortality from COVID-19 infection. Further studies are warranted to address treatment options for this population.

Associations of serum aminotransferase and the risk of all-cause and cause-specific mortality in Chinese type 2 diabetes: a community-based cohort study

OBJECTIVE

Investigating the associations of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) with all-cause, cardiovascular disease (CVD) and cancer mortality in a large cohort of community-dwelling patients with type 2 diabetes mellitus (T2DM).

DESIGN

Community-based prospective cohort study conducted between 2013 and 2014.

SETTING

44 selected townships in Changshu and Huai'an City, Jiangsu province, China.

PARTICIPANTS

20340 participants with T2DM were recruited in Jiangsu province, China.

METHODS

We use Cox proportional hazard models to estimate the HR and 95% CIs of associations of serum ALT and AST levels with all-cause and cause-specific mortality. Restricted cubic splines were used to explore the dose-response relationships between ALT and AST levels with mortality.

RESULTS

ALT and AST levels were inversely associated with CVD mortality, compared with the lowest quintile (Q1), the multivariable HRs of the highest quintile (Q5) was 0.82 (95% CI: 0.66 to 1.01, p for trend=0.022) and 0.78 (95% CI: 0.63 to 0.96, p for trend=0.022), respectively. Furthermore, the HRs for ALT levels in all-cause mortality were 0.90 (95% CI: 0.79 to 1.01, p for trend=0.018), and the HRs for AST levels in cancer mortality were 1.29 (95% CI: 1.02 to 1.63, p for trend=0.023). Stronger inverse effects of ALT and AST levels on all-cause mortality were observed in the older subgroup and in those with dyslipidaemia (all p for interaction <0.05). Further analysis based on gender showed that the associations between serum aminotransferases and the mortality risk were more significant in women and substantially attenuated in men.

CONCLUSION

Our findings suggested patients with T2DM with lower levels of ALT and AST had an increased risk of CVD mortality, which needs confirmation in future clinical trials.

Lower alanine aminotransferase levels are associated with increased all-cause and cardiovascular mortality in nonalcoholic fatty liver patients

BACKGROUND

Serum alanine aminotransferase (ALT) levels are often considered a marker to evaluate liver disease and its severity.

AIM

To investigate the association between ALT levels and all-cause and cause-specific mortality in patients with nonalcoholic fatty liver disease (NAFLD).

METHODS

The Third National Health and Nutrition Examination Survey (NHANES-III) from 1988 to 1994 and NHANES-III-related mortality data from 2019 onward were used to obtain the necessary data for the study. NAFLD was defined as hepatic steatosis, as diagnosed by ultrasound, with no other liver diseases. ALT levels were categorized into four groups according to the different recommended upper limits of normal (ULN) in men and women: < 0.5 ULN, 0.5-1 ULN, 1-2 ULN, and ≥ 2 ULN. The hazard ratios for all-cause mortality and cause-specific mortality were analyzed using the Cox proportional hazard model.

RESULTS

Multivariate logistic regression analysis demonstrated that the odds ratio of NAFLD correlated positively with increased serum ALT levels. In patients with NAFLD, all-cause mortality and cardiovascular mortality were the highest when ALT was < 0.5 ULN, yet cancer-related mortality was the highest when ALT was ≥ 2 ULN. The same results could be found in both men and women. Univariate analysis showed that severe NAFLD with normal ALT levels had the highest all-cause and cause-specific mortality, but the difference was not statistically significant after adjustment for age and multivariate factors.

CONCLUSION

The risk of NAFLD was positively correlated with ALT level, but all-cause and cardiovascular mortality were the highest when ALT was < 0.5 ULN. Regardless of the severity of NAFLD, normal or lower ALT levels were associated with higher mortality than elevated ALT levels. Clinicians should be aware that high ALT levels indicate liver injury, but low ALT levels are associated with a higher risk of death.

Liver Enzymes in a Cohort of Community-Dwelling Older Persons: Focus on Sex Contribution

Dysfunctions in liver metabolic activities may increase the risk of cognitive impairment and dementia. In a cohort of community-dwelling older persons investigated for a suspected cognitive decline, we studied the association between liver status and dementia, considering sex and frailty contribution. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) concentrations, and the AST/ALT ratio were used to assess liver function in 419 older adults (248 persons with dementia and 171 age- and sex-matched subjects without cognitive decline). Although the serum concentrations of the liver enzymes were in the physiologic range, patients with dementia showed lower ALT concentrations (p = 0.005) and higher AST/ALT ratios (p = 0.003) compared to controls. The same differences were found when comparing men with and without dementia (ALT, p = 0.009; AST/ALT ratio, p = 0.003) but disappeared in women. Curiously, comparing women and men with the same diagnosis, the ALT concentrations were lower (p = 0.008), and the AST/ALT ratio was higher (p = 0.001) in control women than men, whereas no significant difference was found between persons with dementia. In conclusion, in our cohort of older people living in the community, the association between serum aminotransferases and dementia was remarked. Moreover, our results support attention to sex difference in liver function, suggesting a role in the pathogenesis of dementia.

Association of the serum transaminase with mortality among the US elderly population

BACKGROUND AND AIM

Considering the inconsistent findings of research into the associations between serum levels of liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST], and gamma-glutamyltransferase [GGT]) and mortality among elderly people, we aimed to investigate the associations of ALT, AST, GGT, and De-Ritis ratio (DRR, defined as AST/ALT) and all-cause or cause-specific mortality among the US elderly people using National Health and Nutrition Examination Surveys data.

METHODS

We included 6415 elderly participants (≥ 65 years). Exclusion criteria included positive test for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus infection at baseline. Multivariable-adjusted Cox regression models calculating hazard ratios (HR) and 95% confidence intervals were developed for each of the liver enzyme measures.

RESULTS

All-cause cumulative mortality was 33.8%, of which 23.8% were cardiovascular disease (CVD) deaths, 15.6% were cancer deaths, and 60.6% were other cause deaths. Adjusted Cox models found increased all-cause mortality risk for low ALT (HR: 1.70), low AST (HR: 1.13), high GGT (HR: 1.25), and high DRR (HR: 1.68). Low ALT and high DRR predicted CVD mortality. Low ALT (HR: 1.91), low AST (HR: 1.16), high GGT (HR: 1.40), and high DRR (HR: 1.76) predicted other cause mortality.

CONCLUSIONS

Low ALT and high DRR were associated with increased CVD and cancer mortality. All serum liver enzyme measures were associated with all-cause mortality and other cause mortality in the US elderly population. Further studies may validate these findings in other elderly populations.

Association of kyphotic posture with loss of independence and mortality in a community-based prospective cohort study: the Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS)

OBJECTIVES

This study aimed to investigate the association between kyphotic posture and future loss of independence (LOI) and mortality in community-dwelling older adults.

DESIGN

Prospective cohort study.

SETTING

Two Japanese municipalities.

PARTICIPANTS

We enrolled 2193 independent community-dwelling older adults aged≥65 years at the time of their baseline health check-up in 2008. Kyphotic posture was evaluated using the wall-occiput test (WOT) and classified into three categories: non-kyphotic, mild (>0 and ≤4 cm) and severe (>4 cm).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mortality and the secondary outcomes were LOI (new long-term care insurance certification levels 1-5) and a composite of LOI and mortality. A Cox proportional hazards model was used to estimate the adjusted HRs (aHRs).

RESULTS

Of the 2193 subjects enrolled, 1621 were included in the primary analysis. Among these, 272 (17%) and 202 (12%) were diagnosed with mild and severe kyphotic postures, respectively. The median follow-up time was 5.8 years. Compared with the non-kyphotic group, the aHRs for mortality were 1.17 (95% CI 0.70 to 1.96) and 1.99 (95% CI 1.20 to 3.30) in the mild and severe kyphotic posture groups, respectively. In the secondary analysis, a consistent association was observed for LOI (mild: aHR 1.70, 95% CI 1.13 to 2.55; severe: aHR 2.08, 95% CI 1.39 to 3.10) and the LOI-mortality composite (mild: aHR 1.27, 95% CI 0.90 to 1.79; severe: aHR 1.83, 95% CI 1.31 to 2.56).

CONCLUSION

Kyphotic posture was associated with LOI and mortality in community-dwelling older adults. Identifying the population with kyphotic posture using the WOT might help improve community health.

Risk Factors of Long-Term Care Insurance Certification in Japan: A Scoping Review

This study aimed to review evidence on future long-term care associated with pre-existing factors among community-dwelling Japanese older adults. We systematically searched cohort and nested case–control studies published between 2000 and 2019 that assessed long-term care certification using the PubMed, CINAHL, and EMBASE databases. The relationship between long-term care insurance information and risk factors was investigated. The protocol was registered with the Open Science Framework. We extracted 91 studies for synthesis, including 84 prospective cohort studies, 1 retrospective cohort study, and 6 nested case–control studies. Certification for long-term care was classified into two endpoints: onset of functional disability and dementia. There were 72 studies that used long-term care certification as a proxy for functional disability, and 22 used long-term care information to indicate the onset of dementia. Common risk factors related to functional disability were physical function, frailty, and oral condition. Motor function and nutritional status were common risk factors for dementia. We found consistent associations between premorbid risk factors and functional disability and dementia. The accumulation of evidence on the incidence of long-term care and associated factors can aid the development of preventive measures. Future studies should aim to integrate this evidence.

Low alanine aminotransferase as a risk factor for chronic obstructive pulmonary disease in males

Alanine aminotransferase (ALT) levels reflect skeletal muscle volume and general performance, which are associated with chronic obstructive pulmonary disease (COPD) development and prognosis. This study aimed to investigate ALT levels as a risk factor for COPD development. This 13-year population-based retrospective observational cohort study included 422,452 participants for analysis. We classified groups according to the baseline ALT levels (groups 1-5: ALT (IU/L) < 10; 10-19; 20-29; 30-39; and ≥ 40, respectively). The incidence of COPD was the highest in group 1, decreasing as the group number increased in males, but not in females. The Cox regression analysis in males revealed that a lower ALT level, as a continuous variable, was a significant risk factor for COPD development [univariable, hazard ratio (HR): 0.992, 95% confidence interval (CI): 0.991-0.994; multivariable, HR: 0.998, 95% CI: 0.996-0.999]. In addition, COPD was more likely to develop in the lower ALT level groups (groups 1-4; < 40 IU/L), than in the highest ALT level group (group 5; ≥ 40 IU/L) (univariable, HR: 1.341, 95% CI: 1.263-1.424; multivariable, HR: 1.097, 95% CI: 1.030-1.168). Our findings suggest that males with low ALT levels should be carefully monitored for COPD development.

Validating care-needs level against self-reported measures of functioning, disability and sarcopenia among Japanese patients receiving home medical care: The Zaitaku Evaluative Initiatives and Outcome Study

AIM

This study aimed to examine the validity of the care-needs levels classified in Japan's long-term care insurance system (LTCI-CNLs) when compared with patients' self-perceived functioning, disability and physical performance among patients receiving home medical care.

METHODS

This was a multicenter cross-sectional study in Japan. Patients who were receiving continuous home medical care and who could respond to the questionnaire were enrolled in this study. In addition to the LTCI-CNLs, the 12-item version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the SARC-F were used to measure functioning, disability and physical performance (sarcopenia). In addition, correlations and associations of the LTCI-CNLs with the WHODAS 2.0 and SARC-F were analyzed using Spearman correlations and linear mixed models.

RESULTS

Data from 181 patients were included in the analyses. The LTCI-CNLs varied, ranging from support level 1 (5.5%) to care-needs level 5 (10.5%), with care-needs level 2 being the most prevalent (24.9%). Moderate correlations of the LTCI-CNLs with the WHODAS 2.0 and SARC-F were found (ρ = 0.58 and 0.44, respectively). Although WHODAS 2.0 and SARC-F scores varied within each LTCI-CNL, predicted WHODAS 2.0 and SARC-F scores increased as LTCI-CNL increased. Dementia was not associated with WHODAS 2.0 or SARC-F.

CONCLUSIONS

The LTCI-CNLs was associated with self-reported functioning, disability and physical performance among home medical care patients. Future studies can use the LTCI-CNLs as an outcome variable for specific care approaches or as a proxy covariate for casemix status. Geriatr Gerontol Int 2021; 21: 229-237.

Low Liver Enzymes and Risk of Dementia: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Low levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in the low physiologic range, surrogate markers for reduced liver metabolic function, are associated with cerebral hypometabolism, impairment in neurotransmitter production and synaptic maintenance, and a higher prevalence of dementia. It is unknown whether a prospective association exists between low liver enzyme levels and incident dementia.

OBJECTIVE

To determine whether low levels of ALT and AST are associated with higher risk of incident dementia.

METHODS

Plasma ALT and AST were measured on 10,100 study participants (mean age 63.2 years, 55% female, 22% black) in 1996-1998. Dementia was ascertained from comprehensive neuropsychological assessments, annual contact, and medical record surveillance. Cox proportional hazards regression was used to estimate the association.

RESULTS

During a median follow-up of 18.3 years (maximum 21.9 years), 1,857 individuals developed dementia. Adjusted for demographic factors, incidence rates of dementia were higher at the lower levels of ALT and AST. Compared to the second quintile, ALT values <10th percentile were associated with a higher risk of dementia (hazard ratio [HR] 1.34, 95% CI 1.08-1.65). The corresponding HR was 1.22 (0.99-1.51) for AST.

CONCLUSION

Plasma aminotransferases <10th percentile of the physiologic range at mid-life, particularly ALT, were associated with greater long-term risk of dementia, advocating for attention to the putative role of hepatic function in the pathogenesis of dementia.

Alanine Aminotransferase and 20-Year Risk of Major Chronic Diseases and Death in a Healthy Cohort Aged 30 to 49 Years

Purpose

Alanine aminotransferase is the most frequently used marker of liver cell injury. We examined the association between alanine aminotransferase levels and long-term absolute risks of morbidity and mortality in healthy Danish people aged 30-49 years.

Patients and Methods

We divided 671 healthy participants from the Ebeltoft Health Promotion Project into four categories based on their baseline alanine aminotransferase values: low (≤10U/l), medium-low (men: 11-34U/l, women: 11-22U/l), medium-high (men: 35-69U/l, women: 23-44U/l) and high (men: ≥70U/l, women: ≥45U/l), and followed them through Danish healthcare registries for up to 20 years. We examined mortality and absolute risks of liver disease, overall cancer, ischemic heart disease, and diabetes.

Results

The risk of any cancer was highest for participants with "low alanine aminotransferase" or "high alanine aminotransferase" (20-year risk: 17.2% [95% confidence interval (CI): 6.3-32.7%] and 18.2% [95% CI: 5.7-36.3%], respectively). The risk of diabetes was highest for participants with "medium-high alanine aminotransferase" or "high alanine aminotransferase" (20-year risk: 12.1% [95% CI: 7.3-18.3%] and 9.1% [95% CI: 1.6-25.1%], respectively). Participants with "high alanine aminotransferase" had the highest 20-year risk of liver disease (20-year risk: 13.6% [95% CI: 3.4-30.9%], while it was 1.0% or less in the other groups). The chance of being alive after 20 years without having been diagnosed with liver disease, cancer, ischemic heart disease, or diabetes was lowest in the "high alanine aminotransferase" group (50% [95% CI: 28-68%]) and 72-79% in the other groups.

Conclusion

Our findings suggest that persons with high or abnormally low alanine aminotransferase measurements are at increased long-term risk of several chronic diseases.

Inverse association of alanine aminotransferase within normal range with prognosis in patients with coronary artery disease

BACKGROUND

Data regarding the association between alanine aminotransferase (ALT) and prognosis of patients with coronary artery disease (CAD) are limited. The aim of this study was to assess the association of ALT with the prognosis of patients with CAD.

METHODS

The study included 9523 patients with angiography-proven CAD who underwent percutaneous coronary intervention. Baseline ALT activity measurements were available for analysis in all patients. The primary outcome was 3-year cardiac mortality.

RESULTS

Patients were divided into three groups: a group with ALT within the 1st tertile (ALT 2.0 U/L to ≤17.0 U/L; n = 3276 patients), a group with ALT within the 2nd tertile (ALT >17.0 U/L to ≤26.0 U/L; n = 3075 patients) and a group with ALT within 3rd tertile (>26 U/L to ≤50.0 U/L; n = 3172 patients). Cardiac death (primary outcome) occurred in 441 patients: 201 (7.1%), 126 (4.7%) and 114 (4.0%) of these occurring in patients in the 1st, 2nd and 3rd ALT tertiles, respectively (with percentages representing Kaplan-Meier estimates of 3-year cardiac mortality); adjusted hazard ratio = 1.43, 95% confidence interval 1.11 to 1.85, P = 0.006 calculated for 1 unit decrement in the logarithmic scale of ALT. The multivariable model for cardiac mortality with baseline variables without ALT had a C-statistic of 0.827 [0.801-0.853], P < 0.001, which increased to 0.832 [0.806-0.857], P < 0.001 after incorporation of ALT (P = 0.020).

CONCLUSIONS

In patients with CAD, ALT was inversely and independently associated with the risk of 3-year cardiac mortality. Low ALT may reflect cardiovascular risk that is poorly mediated by traditional cardiovascular risk factors.